A client is admitted with end-stage cirrhosis and severe vomiting. Which problem should the nurse monitor the client most carefully for?
a. Intrahepatic bile stasis
b. Bleeding esophageal varices
c. Decreased excretion of bilirubin
d. Accumulation of ascites in the abdomen
B
The portal hypertension that accompanies end-stage cirrhosis predisposes the client to esophageal varices. These varices can rupture from increased pressure in the esophagus caused by coughing or vomiting. Bleeding varices can be life threatening. None of the other assessments take priority over monitoring for bleeding from esophageal varices.
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A patient has a disorder which causes progressive, severe muscle pain and weakness, and she has curtailed physical and social activities to accommodate her condition. She tells the nurse "I cannot do anything
I have to depend on other people to help me. I do not enjoy much of anything anymore; even food does not taste good. I cannot see that my situation will change, so I feel pretty hopeless.". The priority action the nurse should take is to: a. point out that there is always room for hope. b. discuss the importance of physical exercise. c. inquire about her support system and coping plans. d. assess for signs depression and risk for suicide.
An office worker takes a cupcake that contains peanut butter. He begins wheezing, with an inspiratory stridor and air hunger and the occupational health nurse is called to the office
The nurse should recognize that the worker is likely suffering from which type of hypersensitivity? A) Anaphylactic (type 1) B) Cytotoxic (type II) C) Immune complex (type III) D) Delayed-type (type IV)
The nurse is assigned a client scheduled for an outpatient colonoscopy in an ambulatory care setting. During which phase of perioperative care would the nurse document the admission vital signs in the recovery room?
A) During the preoperative phase B) During the intraoperative phase C) During the transfer phase D) During the postoperative phase
For the nursing diagnostic statement, Self-care deficit: feeding related to bilateral fractured wrists in casts, what is the major related factor or risk factor identified by the nurse?
A. Discomfort B. Deficit C. Feeding D. Fractured wrists